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Are FPs just supposed to watch as immunity wanes?

10/19/2021
Woman smiling
Dr. Mary Fernando

Last month I wrote about how doctors’ assessments are not impacting which of their patients get covid vaccine boosters.

I interviewed Holly Doan, the publisher/owner and a reporter of Blacklock’s, who works full-time and is a patient on an immunosuppressive drug for an autoimmune disease. 

Holly Doan requested a booste  based on her family doctor’s assessment and letter. “I went to public health to ask about COVID-19 boosters. They told me that I don’t qualify . . . because my immunosuppressive drug wasn’t on the list. I trust my doctor more than I trust an administrator who appeared to not even know my drug. . . . So what’s happening? Why are family doctors not part of the decisions?”

Read: Why COVID boosters weren't tweaked to better match variants

Fast forward a month and Holly Doan has an update. “I asked Ottawa Public Health for a third booster . . .. Less than two-weeks later I got COVID-19.”

"How did I get COVID-19? I don't know. Why did I get sick so easily but nobody in my household fell ill? I don't know. How many people did I infect after Public Health refused a third shot but before I realized I was sick? I don't know."

“Weeks later, I'm still experiencing headache and distorted vision . . .. Do lingering symptoms mean I'm a so-called 'long hauler'?  And the most troublesome question, did this have to happen? Why is Public Health in Ontario refusing third boosters to vulnerable populations? Isn't the point to prevent spread of COVID-19?"

"Memo to Ottawa Public Health: you refused a booster to an immune compromised person who immediately got COVID-19. Is the plan to keep doing this?" 

In Ontario, doctors still aren’t allowed to get their patients their third COVID vaccine, even if the new medical evidence suggests they should have one. In fact, numerous recent articles reassure Canadians that boosters are currently unnecessary, beyond the limited scope of boosters that have been approved. Do these articles tell the whole story? 

Read: National advisory committee recommends booster for seniors in long-term care

So far, the national guidance in Canada for COVID-19 vaccine boosters from the NACI includes “all long-term care residents and seniors living in other congregate settings who have received a primary COVID-19 vaccine series (with a homologous or heterologous schedule using mRNA or viral vector vaccines)”1 and Ontario is offering boosters to seniors in congregate living settings and to those with a small range of illness and medications that make them immunocompromised.2

This is a helpful graphic explaining waning immunity from Dr. Peter Hotez, dean of the National School of Tropical Medicine and professor of Pediatrics and Molecular Virology & Microbiology at Baylor College of Medicine where he is also the co-director of the Texas Children’s Center for Vaccine Development.3

This graphic explains what is missing in the guidance by the NACI and Ontario: the time from the second COVID-19 vaccine dose. Some crucial groups need boosters because their immunity wanes more quickly as a result of drugs or illnesses. Also, there is a failure to recognize age per se as a vulnerability, therefore excluding many community seniors despite the fact that about 90% of seniors over 75 live in the community, so this leaves the most vulnerable unprotected.3

The time out from the second booster is crucial for all of us too, because that is what the experts who reviewed the evidence around the world agree upon.

Read: FDA backs Pfizer COVID-19 boosters for seniors, high risk

The U.S. began giving boosters to those over 65 and is now rolling out third doses for, “people who completed their two-dose regimen of Pfizer or Moderna’s shots six or more months ago are now eligible and lining up for an extra jab.”4 In fact, Dr. Anthony Fauci, White House chief medical advisor and director of the National Institute of Allergy and Infectious Diseases, has reframed the booster shot as part of a COVID vaccine regimen where the “full regimen for vaccination will likely be three doses.”5

In the EU, “The European Medicines Agency . . . concluded that booster doses of BioNTech/Pfizer "may be considered at least six months after the second dose for people aged 18 years and older.”6

The U.K. “announced . . . it will offer a third dose of coronavirus vaccine to everyone over 50 and other vulnerable people to help the country ride out the pandemic through the winter months.”7

Israel, “made booster doses of the COVID-19 vaccine available to everyone age 12 and up who received the second shot at least five months ago, in an effort to combat spiralling coronavirus infections.”8

So why is Canada ignoring what the rest of the experts around the world are recognizing: that immunity diminishes, more so for older people and those with certain illnesses but also from the time from the last COVID-19 vaccine?

Read: COVID-19 boosters: why aren’t doctors allowed to protect their most vulnerable patients?

Some people argue the prolonged interval between doses in Canada may have provided some lasting immunity that is different than the rest of the world. Further, the NACI has claimed that it’s “continuing to monitor the evidence related to waning immunity” and ponders that, “waning antibodies may indicate susceptibility to SARS-CoV-2 infection, while still being protected against severe outcomes.”9

So, is there evidence that fully vaccinated Canadians are getting ill or dying of COVID-19?10 

In New Brunswick, as of Oct. 18, 2021, 20% of those who died from COVID-19 were fully vaccinated—most over 65 years of age. Their immunity has indeed decreased and Rodney Russell, a professor of immunology and infectious diseases at Memorial University of Newfoundland says that, "the reason we're seeing so many vaccinated, mostly older people getting infected now is because they think they're safe . . .. If you can't get a third shot, then you need to act like you haven't been vaccinated because you may not be protected.”

In Saskatchewan, as of Sept. 9, 40% of all COVID deaths were fully vaccinated and most over 60.

A look at Ontario’s hospitalization and ICU numbers also paints a grim picture: 33% of all those hospitalized for COVID-19 are vaccinated with both shots, as are 20% of those in ICU. 

Read: WHO chief urges halt to booster shots for rest of the year

Is the NACI monitoring the serious illnesses from waning immunity and their changing guidance? Obviously, we have some data showing that some over 60 are getting very sick and dying. Should they be included in groups getting boosters? Are there other factors, like the drugs Holly Doan is on, or illness that are allowing people to get infected or even die despite two COVID-19 vaccines? If so, we need to start covering those people with their third shot. In short, the evidence is coming in that, for some at least, two doses of the vaccine is not enough. But we need the guidance to change because the present guidance on boosters is not covering them and some aren’t just getting infected—they’re dying. 

Many experts evaluating the research have concluded that COVID-19 vaccines should be a three dose regimen. Age, vulnerability and time from the second vaccine should be the deciding factors for the third vaccine. 

On the latter point, it is incumbent on us all to recognize that healthcare workers in high risk situations, like ICUs, were vaccinated early and many are eight months out from their second dose. They are being asked to put themselves at risk without the benefit of a third dose. 

We are already struggling with shortages of nurses and doctors: where will patient care be if we have a large swath of healthcare workers infected with COVID-19?

Certainly issues like vaccine equity come into the mix. It isn’t the focus of this article but I would ask, why can’t we both give boosters and also help countries without vaccines get more? We need to ask some crucial questions, because the rubber is hitting the road, and this will worsen as more people get further from their second shot. 

How much illness, long COVID-19 and deaths will we tolerate? How much can our healthcare system sustain if our healthcare workers get sick or die, while patient numbers rise? We can and should do both, but we cannot ignore the reality that is becoming increasingly evident as our immunity from our vaccines wanes. 

It’s time to rethink our strategy of giving third doses to Canadians, because a three-dose regimen of the COVID-19 vaccine is needed.

References

1. NACI rapid response: Booster dose in long-term care residents and seniors living in other congregate settings

2. Ontario Government: COVID-19 Vaccine Third Dose Recommendations

3. HOUSING FOR OLDER CANADIANS: The Definitive Guide to the Over-55 Market

4. More Americans are getting Covid vaccine boosters than first doses in rush for third shots

5. 3-dose COVID-19 vaccine regimen may become norm, Fauci says

6. Europe's drug regulator advises Covid-19 booster shots for the immunocompromised

7. U.K. recommends COVID-19 booster shots for over 50s

8. Israel widens 3rd COVID booster shot to those aged 12 and over

9. One in five N.B. COVID-19 deaths were people who were fully vaccinated

10. Breakthrough COVID-19 deaths are happening in Saskatchewan, so what does it all mean?

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